Clinical Commander

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ob.pre-eclampsia.core.v1

Pre-eclampsia / Eclampsia / HELLP

obstetricsacutepregnancyadultacuteinpatientoutpatient
Start encounter →Print handoutPRODUCTION

Package on disk has atoms.* + regimen.ts + phenotypes.ts but no _design-brief.md — design_brief pointer omitted to avoid broken pointer. Calculator inventory thin: manifest references calc_bmi / calc_map / calc_anion_gap / calc_corrected_anion_gap / calc_ckd_epi / calc_plasmic — only calc.map is in registry; calc.anion_gap and calc.ckd_epi_2021 also exist but added via panels for renal/AKI. No protocol.severe_htn_pregnancy or protocol.eclampsia in registry — IV labetalol/hydralazine/nifedipine + MgSO4 4-6 g load orchestration runs through package regimen.ts only. PRODUCTION blockers: regimen_axes empty (pregnancy-safety regimen builder not yet structured); LOINC list partial. Deepened 2026-05-14 (shard-5-obped-id depth-pass-1): added co-located _briefs/ob.pre-eclampsia.core.v1.md + _research-bundles/ob.pre-eclampsia.core.v1.md (companion to existing _briefs/ob.pre-eclampsia.core.v1.depth.md authored 2026-05-13). Phenotype matrix surfaced (early-onset <34 wk / late-onset ≥34 wk × non-severe / severe-features × no-HELLP / HELLP class I-III × no-eclampsia / single-or-recurrent eclampsia × singleton / multiple gestation × non-superimposed / chronic-HTN-superimposed). First-class TS field for phenotype matrix remains schema-blocked. Refined outpatient setting playbook to surface daily-then-weekly postpartum BP self-monitoring × 6 wk, 6-week comprehensive postpartum visit (ACOG 2025), endocrine-renal review at 6 wk (lipid + fasting glucose / HbA1c + UACR + Cr + BMI per AHA 2021), and explicit next-pregnancy aspirin counseling at 81–150 mg PO daily from 12 wk per USPSTF 2021. Added 4 severity triggers: magnesium_timing_miss (severe — Magpie 2002, 1 h load window), hellp_class_progression (severe — ISSHP 2024), eclampsia_seizure_recurrence (life-threatening — additional 2 g bolus + benzodiazepine bridge), superimposed_severe_hypertension_pulmonary_edema (life-threatening — ICU + cautious furosemide + 80 mL/h fluid restriction). Appended 7 canonical PMIDs (Magpie 12057549, USPSTF 34581729, ASPRE 28657417, CHIPS 25629739, HYPITAT-II 25817374, PARROT 30948284, CRADLE-3 29587875) bringing evidence.pmids from 6 to 13. Confirmed primary_guideline now cites ACOG 222 + ACOG 2025 update + ACOG 767 + ISSHP 2024 + USPSTF 2021 + Magpie + CHAP + CHIPS + HYPITAT-II + ASPRE + PARROT + CRADLE-3. Bayesian linkage (documented in co-located _briefs/ob.pre-eclampsia.core.v1.md): sFlt-1/PlGF ratio > 38 LR+ ≈ 7-9 for delivery within 1 wk (PARROT 2019 / PROGNOSIS 2016); ratio ≤ 38 NPV ~99.3% as T_test rule-out; ASPRE 2017 first-trimester screening derives the pre-test priors; T_treat = magnesium prophylaxis at severe-features confirmation OR clinical eclampsia (Magpie NNT ≈ 100 severe-features); cross-dossier routing to cardio.htn.core.v1 (chronic HTN postpartum > 6 wk), id.sepsis.core.v1 (HELLP + sepsis features), endo.gestational-diabetes.chronic.v1 (sibling). HELLP sub-engine not separately authored — encoded inline. Prehospital recognition state-of-play: encoded via transitions[].admit (outpatient → ed) per depth.md fold-in spec (2026-05-13); a first-class "prehospital" DossierSetting value is schema-blocked. CRADLE-3 Lancet 2019 (PMID 29587875) anchors the low-resource / pre-hospital vital-sign-monitoring evidence base. Fluids field (PE-restrictive 80 mL/h pattern) blocked on FLUID_COMMAND_ENGINES allowlist decision per depth.md spec — not landed this pass. Removed 2026-05-26: DELIVER 36027571 / POINT 29766750 / REDUCE 23900119 PMIDs were copy-paste-template carryover (off-domain: DELIVER=HF, POINT=stroke, REDUCE=Swaziland anaemia) — removed per the orchestrator-gated audit (docs/superpowers/notes/2026-05-26-citation-deep-audit.md).

Entry points (6)

  • vital_abnormality
    BP ≥160/110 in pregnancy / postpartum (ACOG 767)
    severe_htn_pregnancy
  • vital_abnormality
    New BP ≥140/90 after 20 wk (ACOG Practice Bulletin 222 2020)
    new_htn_pregnancy
  • symptom
    Headache + visual changes + RUQ pain (ACOG 222 severe-feature criteria)
    severe_features_symptoms
  • lab_abnormality
    Spot UPCR ≥0.3 / urine protein ≥300 mg/24h (ACOG 222 2020)
    proteinuria_significant
  • lab_abnormality
    Thrombocytopenia + LFT elevation + hemolysis indices (ISSHP 2021)
    hellp_pattern
  • symptom
    New seizure in pregnancy / postpartum (Magpie Trial, Lancet 2002)
    eclampsia_seizure

Required inputs (15)

  • gestational_agerequired
    demographic • used at CONTEXT
    Drives delivery timing (37 wk for non-severe, 34 wk for severe features per ACOG 222 2020); affects fetal viability decisions
  • sbprequired
    vital • used at RED_FLAGS
    ≥160 / ≥110 = severe; sustained × 15 min triggers 30-60 min IV antihypertensive (ACOG 767)
  • dbprequired
    vital • used at RED_FLAGS
    ≥110 = severe per ACOG 222; same trigger as SBP
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    <100K = severe feature / HELLP criterion (ACOG 222 2020; ISSHP 2021)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Cr doubling or ≥1.1 mg/dL = severe feature per ACOG 222; PE-AKI
  • ast_altrequired
    lab • used at INITIAL_WORKUP
    ≥2× upper limit = severe feature / HELLP (ACOG 222 2020)
  • ldh
    lab • used at INITIAL_WORKUP
    Elevated in HELLP (hemolysis); >600 supports diagnosis (ISSHP 2021)
  • haptoglobin
    lab • used at INITIAL_WORKUP
    Hemolysis confirmation in HELLP; differentiates from TTP/AFLP (ISSHP 2021)
  • urine_protein
    lab • used at INITIAL_WORKUP
    UPCR ≥0.3 or 24h ≥300 mg or dipstick ≥2+; not required if severe features present (ACOG 222)
  • severe_headacherequired
    symptom • used at CONTEXT
    Persistent severe headache = severe feature (ACOG 222 2020)
  • visual_disturbancerequired
    symptom • used at CONTEXT
    Scotomata, blurred vision, photopsia = severe feature (ACOG 222 2020)
  • epigastric_ruq_painrequired
    symptom • used at CONTEXT
    Persistent epigastric/RUQ pain = severe feature per ACOG 222; also AFLP / acute pancreatitis differential
  • chronic_htnrequired
    history • used at CONTEXT
    Superimposed pre-eclampsia substrate; CHAP target <140/90 (Tita NEJM 2022)
  • prior_pre_eclampsiarequired
    history • used at CONTEXT
    Recurrence ≥20%; aspirin prophylaxis indication (ASPRE, Rolnik NEJM 2017)
  • current_meds
    medication • used at CONTEXT
    Aspirin prophylaxis status per ACOG 222; ACE-I/ARB teratogen check

12-phase flow (12)

  1. 1FRAME
    Confirm pre-eclampsia (HTN ≥140/90 after 20 wk + proteinuria OR severe features) vs gestational HTN vs chronic HTN vs superimposed pre-eclampsia (ACOG 222 2020; ISSHP 2021)
    inputs: gestational_age, sbp, dbp
    advance: classification assigned
  2. 2ENTRY
    Capture trigger (severe HTN per ACOG 767, severe-feature symptom, lab pattern, eclamptic seizure)
    inputs: gestational_age
    advance: trigger documented
  3. 3CONTEXT
    Capture baseline BP/chronic HTN (CHAP, Tita NEJM 2022), prior PE, aspirin prophylaxis status (ASPRE, Rolnik NEJM 2017), fetal status, severe-feature symptom screen per ACOG 222
    inputs: chronic_htn, prior_pre_eclampsia, severe_headache, visual_disturbance, epigastric_ruq_pain, current_meds
    advance: severe-feature screen + fetal status documented
  4. 4RED_FLAGS
    Sustained severe HTN ≥160/110 × 15 min → IV antihypertensive within 30-60 min (ACOG 767); eclamptic seizure → STAT MgSO4 (Magpie Trial, Lancet 2002); pulmonary edema; HELLP with platelets <50K; abruption; AFLP mimic
    inputs: sbp, dbp
    advance: severe HTN or eclampsia treated; airway secured if seizing
  5. 5INITIAL_WORKUP
    CBC w/ smear (schistocytes), CMP (Cr, AST/ALT, bili), LDH, haptoglobin, UPCR or 24-h urine, T&S, coags + fibrinogen, uric acid per ACOG 222; fetal monitoring (NST/BPP), MCA Doppler if FGR
    inputs: platelets, creatinine, ast_alt, ldh, haptoglobin, urine_protein
    actions: panel.cbc, panel.lft, panel.renal, panel.coag, panel.ua, workup.preeclampsia
    advance: severe-feature labs returned; fetal status documented
  6. 6BRANCHING_WORKUP
    PLASMIC score if TTP suspected (overlap with HELLP per ISSHP 2021); AFLP workup if hypoglycemia + transaminitis + ammonia; head CT if eclampsia atypical / focal deficit; PRES MRI
    actions: workup.preeclampsia
    advance: mimics ruled out or branched out
  7. 7DIFFERENTIAL
    Phenotype per ACOG 222 / ISSHP 2021: gestational HTN, pre-eclampsia without severe features, pre-eclampsia with severe features, eclampsia, HELLP, superimposed PE, postpartum PE; rule out TTP, aHUS, AFLP, lupus flare, secondary HTN
    advance: phenotype assigned
  8. 8RISK_STRATIFICATION
    Severe-feature checklist per ACOG 222 (BP / CNS / RUQ / pulmonary edema / Cr / platelets / AST); Magpie Trial criteria for MgSO4 (Lancet 2002); HELLP Mississippi class; PIERS calculator if available
    actions: calc.map
    advance: severity classified; delivery timing decided
  9. 9TREATMENT
    Sustained severe BP → IV labetalol 20→40→80 mg q10min (max 220) OR IV hydralazine 5-10 mg q20min OR PO IR nifedipine 10-20 mg q20min per ACOG 767; goal SBP <160 / DBP <110 within 30-60 min; MgSO4 4-6 g load → 1-2 g/h × 24-48h for severe PE/eclampsia (Magpie Trial, Lancet 2002); antenatal steroids if <34 wk; delivery is curative — timing per phenotype per ACOG 222 (immediate for eclampsia/HELLP/severe features ≥34 wk; expectant 24-33+6 if stable)
    inputs: sbp, dbp, gestational_age
    advance: BP controlled + MgSO4 running for severe features + delivery plan made
  10. 10DISPOSITION
    L&D / OB ICU for severe features / eclampsia / HELLP per ACOG 222; antepartum admission for non-severe near term; outpatient surveillance only for non-severe remote from term (NICE NG133 2019)
    advance: level of care + delivery timing assigned
  11. 11MONITORING
    Continuous fetal monitoring; BP q15min during severe-HTN treatment then q1h (ACOG 767); MgSO4 toxicity (DTRs, RR, urine output, Mg level if AKI per ACOG 222); platelet/AST/Cr/Hgb q6-12h; daily fluid balance; postpartum 72-h continued risk
    inputs: sbp, dbp, platelets, creatinine
    actions: panel.cbc, panel.lft, panel.renal
    advance: mother and fetus stable; postpartum monitoring through 72h-2wk
  12. 12FOLLOWUP
    BP check 3-7 days postpartum + 1-2 wk + 4-6 wk per ACOG 222; lifelong CV risk follow-up (PE doubles future CV risk per AHA 2021); aspirin 81-162 mg from 12-16 wk in next pregnancy (ASPRE, Rolnik NEJM 2017); AHA/CDC postpartum hypertension awareness
    advance: postpartum BP plan + lifetime CV surveillance documented